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Diabetes Algorithms v0 0 1 PDF
Diabetes Algorithms v0 0 1 PDF
Diabetes Algorithms v0 0 1 PDF
and
Education of the patient is paramount and continuing lifestyle advice is essential. DSME (Diabetes
Self Management Education) is an essential step to attaining good quality self management. A life
long condition needs life long learning. It is important to ensure the patient understands that diabetes
is a progressive disorder and this requires ongoing coaching, education and support. However medication
to control diabetes and its complications is almost inevitable. This set of algorithms is produced to
assist management and hopefully reduce the number of patients with high HbA1c in the Waitemata
District Health Board Area.
This version is produced by Dr Catherine McNamara, Dr Rick Cutfield, Dr Walter van der Merwe, Lynn
Randall, Harbour Health, Lesley Hawke, Pharmacist WDHB and Jo Knight PMP.
indicated (see note 1 d) get CG (capillary glucose) stabilised (see note 1c) • Podiatry
Patients need 3-6 monthly HbA1c and will progress at different rates
Start with 6 -10 units of Protaphane or Humulin NPH, titrate When is it the right time?
dose by 2-3 units every 3-4 days until required SMBG levels • Consider starting insulin when appropriate for individual
are reached (see glucose targets overleaf) patient and HbA1c is above 8%(64 mmol/mol).
• Coach the patient to continue to make appropriate lifestyle changes
• Consider starting nocte insulin for consistently high fasting • Ensure maximum dose of oral hypoglycaemic agents has been
morning SMBG readings reached, unless contraindicated.
• If SMBG readings are consistently higher during the day, • Ensure patient is well educated on starting insulin e.g. dietary
then may consider starting mane insulin (especially in elderly) requirements, use of metre and pens, Tx hypoglycaemia
• Aim for a pre-breakfast reading of 5.5-7.5 mmol/L • Provide patient with starting pack which includes pen, log book,
• Continue oral hypoglycaemic agents e.g. Metformin 1g bd script, needles, written instructions and 'hypo' management
(providing no renal impairment) with or without a sulphonylurea information with contact details in case of emergency.
STEP 2: ADD CALCIUM CHANNEL INHIBITOR ALLOW 2-6 WEEKS between each dose
(see note 2) adjustment
and
In those who have risk factors but without known CVD, the minimum aim is to lower Maori and Pacific Island patients- consider starting statins earlier for those who
LDL to less than 2.5mmol/L (although Canadian Diabetes Assn. and NZ Cardiovascular appear to have increased CV risk independent of traditional risk factors.
Guidelines say less than 2.0 mmol/L). Alternatively, one might aim for at least a 30-
40% reduction from pre-treatment level, and/or a Total Cholesterol /HDL ratio of less For Lifestyle Guidelines see C/V Guidelines NZGG.
than 4.0. In those with a previous cardiovascular event a target LDL of less than
1.7mmol/L is appropriate given a further reduction in events with more aggressive
LDL lowering.
For patients with severe fasting hyper triglyceridemia review secondary causes
(e.g. alcohol, hypothyroidism, renal or liver disease) and consider treatment with
fibrate if TG more than 4.5mmol/L. Most commonly, Bezalip Retard 400mg is used
References New Zealand Guidelines Group (2003). Evidence-based best practice guidelines: management of type 2
Texas Diabetes Council Lipid Algorithm for Type 1 and 2 Diabetes Mellitus in Adults accessed on 18th May 2010 diabetes. Wellington.
New Zealand Guidelines Group (2009). NZ Cardiovascular Guidelines Handbook, Wellington. www.diabetes.ca/for-professionals/resources/2008-cpg/ - accessed on 1st June 2010
Guidelines www.nice.org.uk/ - accessed on 1 June 2010
Diabetes Service, Waitemata DHB
Diabetic Foot Referral Criteria Screening: Does the patient have any of the following “At Risk “Features?
• A history ulceration/amputation/Charcot neuroarthropathy
YES • Active foot problem – ulcer, infection (acute/non acute) deformity causing callus/corns
• Absent pedal pulses
• LOPS-Neuropathy with Insensitivity to 5.07 Semmes Weinstein monofilament
NO
NO
Lipids
For those with an established cardiovascular For those over 45 years treat with statin For those less than 45 years with at least
event e.g. MI, PVD, CVA or Microalbuminuria With a target of LDL 2.0-2.5 mmol/L one other cardiovascular risk factor
The target is LDL 1.7 mmol/L or at least 30- or LDL < 30-40% of initial pretreatment Target is LDL <2.0-2.5 mmol/L
40% of initial pretreatment level level and /or Chol/HDL <4.0 or LDL < 30-40% of initial pretreatment
level and /or Chol/HDL <4.0
REFERRAL GUIDELINES TO THE SECONDARY CARE DIABETES SERVICE
Introduction • Patients with Type 2 Diabetes with significant complications and those with poor
Diabetes is a chronic condition which requires good understanding and management control or problems with recurrent hypoglycaemia
skills by the patient and regular surveillance and support from a health practitioner • Any other issues which are difficult to resolve in the primary care setting.
team. Type 2 diabetes is usually associated with other vascular risk factors which • Any patients pregnant or conisdering pregency refer or discuss with Diabetes Team
require equal attention (see treatment algorithms for BP & Lipids).
Checklist for Newly Diagnosed Patients with Type 2 Diabetes Telephone Advice and Support for Practices:
1. DSME : All patients with newly diagnosed Type 2 diabetes should have the The Endocrine Registrar can be contacted for urgent telephone advice during office
opportunity to attend a Diabetes Self-Management Education (DSME) course. hours and will liaise with consultants for advice if required. Diabetes Nurses can
Patients with more long-standing disease may also benefit from the support and also provide urgent telephone advice. The Diabetes Team may be available to visit
advice provided by DSME. If a patient is unable to attend a PHO run DSME course, practices for educational sessions and for support around insulin starts etc if required.
please consider the patient for a Diabetes Auckland course or 1:1 advice from a
suitably qualified practice nurse or dietitian. Contact For Contact Number
2. Retinal Screening: Patients should be referred for Retinal Screening on diagnosis.
3. Foot care: Observe for any indications of peripheral neuropathy by completing Endocrinologist GP advice 021 242 8702
a thorough foot check and educate the patient about regular care of their feet.
Physicians Please contact Endocrine 486 8900
Consider referral to a community Podiatrist for initial assessment if indicated.
Registrar via switchboard
Treatment
Diabetes is a chronic progressive condition. Newly diagnosed patients will require After hours advice Medical Registrar on call 486 8900
lifestyle advice and commencement on metformin. Regular monitoring of HbA1c
and other parameters should follow the recommended stepped approach to oral Diabetes Specialist Nurse Ext 2505 486 8900
medications and then onto insulin (see treatment algorithms provided).
Education about, and reinforcement of, advice to comply regularly with medications How to refer patients for assessment in clinic:
and adopt appropriate lifestyle measures is essential in facilitating better understanding Please include the following clinical details:
of the condition. • Duration and type of diabetes
A FREE ANNUAL “GET CHECKED” ASSESSMENT SHOULD BE OFFERED TO ALL • Current medication
PATIENTS WITH DIABETES. • Recent HbA1c and any other results if available
Subsidised programs such as Care Plus should be utilised where possible, especially • Brief summary of problem necessitating referral
when financial restraints are preventing the patient from accessing the Primary Care Please send referrals to: Fax 441 - 8986
service or obtaining follow-up prescriptions. Guidelines for discharging patients back to Primary Care:
After a period of initial assessment and follow-up, our aim will be to discharge
Who to refer to the diabetes clinics at North Shore and Waitakere Hospitals patients back to primary care with a plan of care. For patients with Type 1 Diabetes,
• Patients with Type 1 diabetes we will continue to see once per year where possible, as these patients are on more
• Adolescent patients with any type of diabetes complicated insulin regimens etc.
• Patients with nephropathy (eGFR<40 or significant proteinuria). (Refer to Renal All patients are actively encouraged to visit their GP as their primary care giver
Service or Diabetes Service depending on stability of diabetes) regardless of their attendance at diabetes service.